Billing Of Specialty Pharmaceuticals

Written by Norene Anderson

The billing of specialty pharmaceuticals is a mounting problem for many providers and physicians. More than $35 billion is spent on specialty drugs, mostly injectables, yearly. Hundreds of biotech drugs are coming down the drug pipeline. It is expected that within one to two years the amount of yearly cost will be near $60 billion.

Proper billing of specialty pharmaceuticals is essential for the physician and the patient. The average price for an injection of a specialty drug is between $1,000 and $1,500 per month. The management of drug utilization is crucial for making sure the patients have access to the needed medication. There are many safety concerns with the continual arrival of new drugs on the market. Most of the new biotech drugs have a short shelf life making it critical to plan carefully for each injection.

Changes for Billing of Specialty Pharmaceuticals

One of the dilemmas facing the billing of specialty pharmaceuticals is the change in reimbursement for injectable drugs. In the past, they were reimbursed as part of the medical benefit of a health plan. With more of these medications being injected by the patient at home or by a home health agency, new methods of identifying specialty pharmaceuticals for billing are being introduced.

The use of formulary programs is used by many plan sponsors. This is one way to manage and control the cost and benefits of the medication. A formulary is a preferred drug list of prescription drugs usually covered under a pharmacy benefit plan. This list will include FDA approved generic and brand-name drugs. These drugs are not all inclusive, but they are the ones that insurance providers have contracted with for a volume discount.